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What Is Your Life Worth?

Sunday, September 2nd, 2012

By BirdStrike M.D.

“Good, it’s about time that these greedy doctors get smacked down for being the financial rapists that they are.  Medicine in this country is the biggest, most destructive SCAM going on today. Doctors think they are entitled to RIDICULOUS amounts of money for simple routine procedures.”- Johnathan Blaze August 27, 2012 at 4:54 pm

It is generally agreed upon that the more one values a good or service, the more he or she is willing to pay for it.  Most will agree that shoes are important.  They keep your feet from bleeding and hurting when you walk on the street.  People seem happy to pay anywhere between $20-$150 for them.   Some will clamor to pay without complaint as much as $315 for sneakers that mimic those of their favorite basketball hero, or $865 for designer Manolo Blahnik “BB” Snakeskin Pumps.  Many place great value on a youthful physical appearance and sex appeal and will gladly pay up to $15,000 cash for a new pair of breasts with little if any sense of resentment for the doctor providing the service and metering the charge.  Having a car, most of us will agree is very important, and therefore paying around $30,000 is pretty average.  Though it seems that many are outraged at a Plastic Surgeon charging $12,000 to repair a fingertip, most people consider their limbs and appendages important, and being able to use them of significant value.  Therefore, it follows that a total cost of approximately $40,000 for a hip replacement tends be generally well accepted and frequently paid by insurance companies along with the physician portion of $1,505 (CMS CPT 27130.)

So how much is your life worth to you?  Clearly it is worth more than a pair of shoes.  Are we still in agreement?  Certainly you would be more than happy to pay $20-$150 to have it saved, if you or your insurance company had the finances.  Is a human being’s life in total worth more than the $15,000 pair of augmented breasts on the human being?  I’m sure most would agree it is.  I’m sure as a society we must pay more than this for a human life saved, correct?  I’m sure we all similarly agree that the entire value of a human life saved is greater than the value of a “spare replacement part” such as a $40,000 hip.  We must certainly and gladly pay those who save our lives at least as much as we pay for sneakers, designer shoes, our cars or a spare hip, correct?

No.  We don’t.  It’s not even close.

In the field of Emergency Medicine, there are only a few situations where the physician can truly walk in a room and walk out a few minutes later absolutely certain he saved a life.  One is an emergency intubation (making a non-breathing person breath again) and another is cardioversion/defibrillation (restart a non-beating heart.)  It doesn’t always happen every day, but it is what Emergency Physicians and other critical care providers are paid to do.  To be an Emergency Physician is a paid position.  It is not a volunteer position.  It stands to reason that Emergency Physicians would be paid at least as much as for a life saved as for the aforementioned goods and services, correct?  Let’s break down what a true life-saver gets paid to save an entire life, not just the hip, the breasts, the fingertip or the shoes.

What an Emergency Physician actually gets paid to save a life-

1)      Emergency intubation: $112  (CMS payment for CPT 31500) or,

2)      Cardioversion/Defibrillation: $131  (CMS payment for CPT 92960)

Even if one combines cardioversion with a $226 charge for critical care services provided (CMS CPT 99291) the total charge is still only $357. Therefore, according to the United States Center for Medicare and Medicaid Services, your life is worth $357, or at least that’s what they’re willing to pay Emergency and Critical Care Physicians to save it.  This doesn’t factor in the number of people who are still uninsured and unable to pay anything.  In other countries the payments are even less, or are lumped into a salary that if broken down service by service doesn’t come close to even this amount.  Any outrageous bill from such an Emergency Department visit is and only can be from the hospital itself.  Zero of the portion of the hospital charges go to the Emergency Physician.  Zero.  This is a fact.  So, to paraphrase the above commenter, is $357 a “ridiculous amount of money for a simple routine procedure?”

I am not an economist, nor a philosopher, but this all seems to follow a theory of sorts, that I have observed.  There may be an official theory of economics of which I am unaware that explains this.  This may or may not be an original thought or observation (economists: if not, please place source in comments section and I will cite it.)

The extent to which the value of a service to an individual approaches infinity (such as a human life saved), is the extent to which a person expects it to be provided to them for free.  Any charge for this infinitely valuable service will not be considered a very fortunate undercharge.  Instead, the extent to which there is any charge at all for the infinitely valuable service, is the extent to which the receiver of the service will harbor undue resentment toward whomever profited any amount from providing it.

It is for this reason that an Emergency Physician that asks to be paid $40,000 for giving someone a new chance at life is considered greedy and contemptible, yet the hospital and orthopedic surgeon that ask for the same payment for a spare hip are not.

It is for this reason that the Emergency Physician that expects to be paid $15,000 for a life saved is wrong, yet the Plastic surgeon is right to charge, and is happily paid by his “customers” $15,000 for a beauty enhancement service.

It is the same reason, Manolo Blahnik is a “life-saver” for trading beautiful shoes for the fee of $865, but an Emergency Physician is expected to feel fortunate to be paid hundreds of dollars less than this for a life saved.

I am not suggesting that Emergency Physicians (in the United States) aren’t paid well, because they are.  I am also not suggesting that orthopedic surgeons, plastic surgeons, shoe designers or anyone deserves less than that which they rightly earn.  Also, I am by no means implying that Emergency Physicians are, or should be, motivated by primarily by money, nor that those with life threatening emergencies should have their lives held hostage and be price gouged.  I am not even suggesting that for life saving services Emergency Physicians should be paid a fee equivalent to performing a hip replacement, breast implant operation or a pair of luxury shoes.  I am suggesting, however, that if they were, they would certainly deserve every penny.  My main assertion is that if people and society are not going to pay life-savers that which a life saved is worth, or even what they gladly pay for a new hip, pair of breasts or luxury shoes, that at a minimum they hold Emergency Physicians, nurses, EMTs and other emergency service workers in the highest regard.

Some patients give great thanks when treated for true emergencies in the Emergency Department.  However, many others, for some reason, rather than showing great appreciation or at a minimum rewarding the providers of such infinitely valuable and life-saving services with compensation comparable to that of products and services of definitively much less valuable ones, often times the payment is instead the toxic and misguided negativity of those such as the commenter above.  It is very unfortunate.

Clearly, the economics of our healthcare system are warped and distorted in countless ways, and far and away those who profit the most are the insurance companies and hospital mega-corporations, not the Emergency Physicians, nurses and other providers.  However, to point the finger of blame at those who are on the front lines of the trauma and chaos, with the highest burden of burnout, who also get paid a small fraction of the payment of other medical services for the service of saving a life, seems to me at best misguided, and at its worst sick and twisted.  How much longer they will choose to do so I am not sure, but thank God, the unappreciated heroes of the Emergency Departments of the world can make their way through the negativity, sleep deprivation, and stress to be there to save the lives of all of us, including even those who resent and condemn them the most.  To them, I say, thank you.

(Financial disclosure: In my current practice I do not bill the above mentioned procedure codes and would not benefit financially from any increase in reimbursements for these, or any other emergency procedures or services.)

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This author does not divulge protected patient information or information from real life court cases. Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients. To the extent that any post is based on the real life experiences of the author, names, dates, ages, sexes, locations, diagnoses, and all other factual information are routinely changed to the extent that it should be considered fictional.  Any opinions expressed here are of the author alone and not those of EP Monthly or WhiteCoat.

Tony the Doorman

Sunday, August 12th, 2012

By BirdStrike M.D.

I’m sitting in my apartment on the West Coast starving, listening to my stomach growl, waiting for my pizza to be delivered.  It is taking unacceptably long.   I’m going back and forth on how little I can tip the pizza delivery man without feeling too guilty to actually enjoy the pizza if and when it ever arrives.  There’s a knock on the door.  Thank God, I think to myself, it’s about time.

I open the door, “Pizza’s here,” says the pizza man.  “You’re the best doctor in the world!”

“What?” I say.  “Yeah, the doorman says you RULE!  He said if I ever need to get checked out, to go see you.  He says, ‘You da man!’”

“Oh, that’s just Tony the doorman,” I say shaking my head.  “Don’t listen to him.  He says that all the time.”

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I pick up a chart in the ER, back when there still were things called “charts”, and it says: “Tony ***** 37-year-old male.  Chief Complaint: Back Pain.”  I walk in the room and it is Tony the doorman of my apartment building, nervous, sweaty and pacing the room, with his jet-black hair slicked back and his gut as huge as always.

“Tony!  How are you doing?  Good to see you.  What brings you in here, today?”

“Doc.  You gotta’ do somethin’.  My back’s killin’ me.  I’m dyin’ here,” he says in his tough-guy accent, as he nervously paces the room.

“Where does it hurt?” I ask.

“Right here,” he says, pointing to his upper back, “right between da shoulder blades.”

“When did it start?” I ask.

“Just a couple hours ago.  I didn’t do nuttin’.  I was just sittin’ there and it hit me like a ton of bricks.  I didn’t fall, lift anything heavy or hurt myself at all.  I’m dyin’ here doc.  You gotta help me.  I need something for this pain,” says Tony.

“What does it feel like?” I ask.

“It feels like someone’s got a sledge-hammer on my back.  Seriously, man.  I’m dyin’ here.  Come on.  Do something doc.  Make this pain go away.  I need something for this pain.  Please.”

“Is there anything that makes it any better?  Anything that makes it hurt worse?” I ask.

“Nope,” he says.

“Does the pain move?  Does it radiate?” I ask.

“No,” he says, “it’s just right there in da middle of my back?”

“By chance, is it a ‘tearing pain’ right between your shoulder blades?” I ask.

“Not really,” he says, “it just hurts!”

My gut is telling me that something is not as it appears.  I have the nurse give Tony a dose of Morphine while I continue to get the history.  Tony proceeds to tell me that he doesn’t drink, smoke or use any illegal or prescription drugs.  Also, he reports no significant medical problems, and no significant family history.  He also denies any history of chronic pain of any kind.  His physical exam is completely normal including his vital signs with equal blood pressures in both arms.

“Alright, Tony, the nurse is going to give you another dose of the pain medication.  We’re going to get a chest x-ray and see what that shows.  I’ll be back in a few minutes,” I tell him.  My gut is telling me, that there is something Tony is not telling me, but my brain is telling me that if Tony’s upper midline back pain is from a thoracic aortic dissection, and he dies from it, I’ll never forgive myself.

“Doc, it’s starting to hurt right here,” Tony says, pointing to his chest.

Bingo, I tell myself, it’s IS a dissection.  I order a CT of the chest with IV contrast, d-dimer, basic labs and cardiac enzymes.  Wait!  His EKG?  Did we do an EKG? I ask myself.  I honestly can’t remember at this point.  I could have sworn I looked at one and it was normal.  They wheel him off to CT and I go pull up his chest x-ray.  It’s normal; painfully normal.  I walk over to the CT suite to look at the images as they load onto the screen and to take another look at his chart to see whether or not I had looked at an EKG.  There it is, on the chart.  It is in fact, completely, stone-cold normal.  I breathe a slight sigh of relief.  I watch as the cross sections load on the computer screen.  His aorta looks as normal as can be.  I’m not a radiologist, but I can usually spot a big tearing aortic dissection on a well done CT scan, and this one looks perfect.  Of course it does.

I turn the corner to the main ED, and I’m hit with the all too familiar sound and smell of ambulance sirens and exhaust blasting through the double doors, monitor alarms frantically beeping, patients crying, doctors and nurses sighing.

“Tony, all of your tests came back perfectly normal.  I honestly cannot tell you what is causing this pain, at this point,” I explain. I know exactly what’s causing this pain, I think to myself.  “It’s probably nothing serious.  Most likely it is musculoskeletal back pain or some acid reflux causing esophageal spasms.  I think we’ve ruled out most of the ‘bad stuff’,  however, it is concerning that this pain is so severe, especially since it is in your chest.  The chance of this being a heart attack is extremely low, statistically, but I’d like to keep you in the hospital overnight.  It’s just a precaution.  You’re only 37 years old, you really don’t have much in the way of risk factors for heart disease, but you know what, I’d just feel better if we watched you overnight.   Is that alright?”

“Doc.  I need some more of that pain medicine,” says Tony.

Just then Melba, an old battle-axe ER nurse who I would shutter to ever run into in a dark alley, decides upon herself to start doing another EKG.

“Melba, we don’t need another EKG.  Why are you doing another EKG?  The first one was completely normal.  We’re just going to give him some aspirin, nitro-paste, another dose of morphine and get him admitted.  Cancel the repeat EKG.  Okay?  Stop,” I bark at her.  Ignoring me completely, she shoots me with a glance from her evil Melba eyes and peels the EKG off the machine and flings it at me.  I look at it:   T O M B S T O N E S .  Uh-oh.  We went from a totally normal EKG, to a massive acute myocardial infarction, in a 37-year-old male with no practically no risk factors.  Wow.  Tony is dying.

“Tony, you alright?” I ask, as his face drains white.  “Melba, put the pads on him,” I order. His eyes drift off, and his head slumps to the side.   Tony’s dead.  “Oh, sh–!  V-Fib.  Get the pads on him now!  Gimme the paddles now!  Charging.  Everyone clear?!”

POP!

After 10 seconds of V-fib, and with a massive jolt of electricity directly through his heart, he is now back in normal rhythm.  Tony’s alive.  Thank God.

Off to the cath-lab goes Tony and there I stand scratching my head thinking, how in the world could I have been so wrong about this guy?  I had him pegged as wanting nothing but morphine and he’s burning up myocardium.  Geez.  I could have seen myself sending this guy home with little or no work up.  A 37-year old male?  Back pain?  No cardiac risk factors?  Acute MI with a normal EKG on presentation?  Holy crap!  I almost missed it.  If I had sent him home, he’d be dead!

A few weeks later, I’m practically falling asleep while walking into my apartment lobby at 8 am after the first of several night shifts.  There’s Tony, back at his doorman post.  I duck down and head toward the stairs trying to sneak by unnoticed, feeling like a complete idiot at having almost misdiagnosed his heart attack.  “Doc!  Get over here!  Now!” screams Tony.  I stop.  I’m busted.

Tony runs over and surprises me with a  M A S S I V E  chest bump with his huge gut almost knocking me over and then follows it up with a huge bear hug.  “You saved my life.  You saved my life!  You’re the best doctor in the world.  I was having a heart attack.  Can you believe it?!  I was having a HEART ATTACK!”

“No, I can’t, I mean uh, yes actually I knew it from the minute you walked in the door.  Yes.  Thanks.  I’m glad you are not dea….I mean I’m glad you are doing so well,” I say.

“I’m gonna tell everyone you da’ man!  I’m gonna send EVERYONE to the ER to see you, doc!” he yells.

“No, please don’t do that….I’m mean, thanks, but I’m an ER doctor, and I don’t really have my own office, and you know it’s really busy there and we don’t need any more patients.  Uh, I mean…you know what I mean, don’t you?  But thanks, really, I’m glad everything turned out all right,” I stammer.

“I’ve never felt better in my life.  Thanks again, doc,” he says.

Tony worked the door at my apartment for two years after that and suffered no ill effects from his heart attack.   Then one day Tony didn’t show up to work.  No one seemed to know if he quit, moved, got fired, or where he went.  But for those 2 years Tony the doorman told every single relative of mine, pizza man, friend, paper boy, mail man, or random stranger in the lobby that I saved his life and that I was the best doctor in the world.  I couldn’t believe it.  I thought he would do it for a few weeks and forget about it, but he never did.  Every chance he got for the 2 years that he worked there, he would loudly and proudly announce to everyone he could, that I saved his life.  As you can probably imagine, it is not rare to save a life in the ER.  However, to actually have someone go out of their way to thank the ER doctor and nurse who saved that life is rare.  For whatever reason, Tony did his absolute best to say thanks not only for himself, but for everyone else that either just didn’t think to say it, or was too busy, sick, tired or stressed to do so.  I don’t know where Tony the doorman is today, or if I’ll ever see him again, but if I do there’s one thing I’d like to tell him:  “Tony, thanks for saying thanks.”

 

 

 

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This author does not divulge protected patient information or information from real life court cases.  Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients.  To the extent that any post is based on the real life experiences of the author, names, dates, ages, sexes, locations, diagnoses, and all other factual information are routinely changed to the extent that it should be considered fictional.  Any opinions expressed here are of the author alone and not those of epmontly or WhiteCoat.

A Nameless Faceless Killer

Friday, August 3rd, 2012

By BirdStrike M.D.

1) A 40-year-old female sees her family physician for burning chest pain after she eats hot peppers. She had it only once while exercising. Her family physician sends her to the emergency department and she gets admitted for chest pain. Rather than going home with treatment for her GERD, she ends up dead. This never should have happened, but the family never learns what really killed her.

2) A 33-year-old father of 3 dies on a hospice ward, bloated with steroids, on tube feeds with a tracheostomy. He was stricken down too young, his family is told, by a rare form of brain cancer. It was an unlucky fluke, they are told, but that is not the only reason.

3) A 7-year-old boy dies in the Pediatric ICU. His family is stunned, shocked and devastated. How could this have happened? The family is told he died from an ingrown toe-nail infection that spread to his blood stream and caused a severe form of sepsis. “It could happen to any of us.” They do not know that the breeding of this superbug was fed by a nameless killer.

4) A 16-year-old girl is on a CT scan table nervously giggling. Fifteen minutes later, she goes into cardiac arrest. A short time later, a solemn nurse informs her family that the patient has died from an allergic reaction. But her cause of death is something more insidious.

Each of these patients had a different doctor, but a similar contaminant. Much like a baseball slugger whose home run swing at a 100 mph fastball is thwarted when a camera flash from his biggest fan causes him to blink; the doctors were thrown off of their game. The culprit: Defensive Medicine.

In each case presented, the doctor had a very rational fear of being sued for either making a mistake or even for doing everything right. During the last moment in the rapid-fire decision-making process, each doctor had a “flash in the eye.” In each case, the result was a swing and a miss. Over and over, and over again in hospital wards, emergency departments, operating rooms, and doctors’ offices in America doctors are being told they must rule out every possibility or be sued. The ones who suffer are the patients, often tragically so. Why? Rather than trusting their instincts, the treating physicians are instead asking themselves, “What could a medical malpractice attorney possibly say I should have done?” While this may seem like a dangerous way to practice medicine, often the doctors have very little choice but to do so.  Consider the stories behind the cases presented above:

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Why Some People Just Will Never Get It

Wednesday, July 25th, 2012

By BirdStrike M.D.

This post was inspired by a brilliant response by Lior to WhiteCoat’s excellent article “Jim Dwyer New York Times Pediatric Fever Article Debate” on this very blog.  First, what should not be lost in this back and forth debate are Rory Staunton and his family.  I give my deepest condolences to the family of Rory Staunton. As a parent, I cannot imagine their pain. I wish them and the rest of his family the best. I sincerely wish that this had not happened, and that this outcome never happens to a child again.  My intent is not to “take sides” or play judge and jury over the treatment in this case.  In contrast, I would like to underscore what it is like to be an Emergency Physician, and how sometimes tragic and devastating outcomes can occur, when a competent, concerned, hardworking Emergency Physician does everything right.  I think Lior gets it like very few non-medical people ever will. Put another way:

1. Common things presenting commonly-

When a patient presents with something common with its usual symptoms, the diagnosis is obvious to medical practitioners and even lay people.  Runny nose, dry cough = common cold.  99% of the time that equation is correct.  We all get it.

2. Uncommon things presenting commonly-

The difficulty of a diagnosis increases significantly when a patient presents with an uncommon condition, yet with its typical symptoms. Physicians typically are well trained to make such diagnoses.  Petechial rash, fever, stiff neck = devastating, fortunately uncommon, but easy to identify: Meningococcal meningitis.  Cases like this are easy, even if you’ve never seen them.  This is what doctors do.

3. Rare things presenting commonly-

Once again, the difficulty of diagnosis jumps even more dramatically when a patient presents with a very rare and unlikely condition, yet with its typical symptoms. Again, physicians typically do a good job here; this is what board exams prepare for, finding the “needle in the haystack”.  A 14 year old male with tearing back pain between his shoulder blades = Marfan’s Syndrome with thoracic aortic dissection and impending death.  Rare, thank God, and easy to miss if you are not extremely careful, but right out of the textbook if you are so unfortunate to see this case and fortunate enough to recognize it.

4. Uncommon things presenting uncommonly-

When a patient presents with an uncommon, or worse yet rare condition, presenting with symptoms that are unusual even for the uncommon condition itself, the difficulty of making the diagnosis increases logarithmically to the point where missing the diagnosis is essentially expected.  Others have put it like this:  there are some diseases that are so uncommon, and can present so unusually that it is essentially the standard of care to miss them.  The 11 year old boy with nausea, sweating with pain down his arm:  It’s obvious, right?  It’s obvious what this is.  It’s an early case of sepsis, from a cut on the arm, presently very strangely, correct?  After all, the heart rate is 130.  The respiratory rate is high.  The temp is 100.1 F.  “He’s just not right.”  It’s sepsis, right……?  Maybe it is a viral gastroenteritis.  Or what if I told you the boy was a chronic complainer, and faked sick to get out of school many times?  And after some nausea medicine, he says he feels a little bit better and just wants to go home…

But his chest hurts, too.  And when he was younger he had Kawasaki syndrome, which was treated, but caught very late.  Would you know that he was dying in front of you from a disease that almost never strikes the young?  Would you think to order an EKG?  Would you think that your 11 year old nephew was having a massive and fatal heart attack, 60 years before his Grandpa did?

What non-medical people just will never get, is that when “uncommon things present uncommonly” while working in real time, sometimes such a diagnosis can be a shot in the dark for even the best, most careful Emergency Physician.  However, when you work backwards after the fact, it’s easy.  It’s classic.  Any 4th year medical student could name it.  A young boy who has a rare disease called Kawasaki syndrome, and recovers, but is now at risk for having what would otherwise be unheard of: dying of a heart attack at age 11.  It’s easy after the unthinkable makes itself known.  But when the 11 year old boy comes in to your Emergency Room with nausea and pain down his left arm, your mind doesn’t scream, “EKG! EKG! Get an EKG idiot!” like it would if you changed the number 1 to a 6 and made him 61.  Do you get it now?

In the current medico-legal climate 100% accuracy is expected 100% of the time, while at the same time being expected to decrease the tests we order to save money for “the healthcare system” under the threat of multimillion dollar lawsuits and now in 2012, slander and libel. This would equate with finding the “needle in the haystack that is disguised as a strand of hay” with a gun held to your head.  This is what non-physicians, lay people, and juries do not understand, and probably never can. Very few people operate under stakes so high, with lives on the line, time pressure, lawsuit pressure, declining pay, and the requirement to be 100% accurate with diagnoses that you may have a 1 in a million shot at making. There just is nothing remotely equivalent in the worlds of most lay people, and that includes people who make more money that a doctor writing for a living. It’s like a passenger-jet pilot flying into an unexpected stormy cloud formation, with winds blowing how they don’t usually blow, with an airplane that has controls responding how they don’t usually respond. It may only happen 1 in every 250,000 flights, but when it does the results can be catastrophic by no fault of his own. I’m sure pilots get it. When uncommon things present uncommonly, pilots can pay with the lives of others and their own.  I’m sure police officers get it. They may be faced with a situation they never practiced in training.   A shadow comes out of the dark with a gun.  Should he shoot or not?  The answer is easy, right?  No, it’s not.  Not until you know who the dead man is.  Is the shadowy figure the mad man?  Or is it the officer’s partner?  Does he decide now, or a 1/10 of a second later?  His life, or his partner’s life, or the mad man’s life depends on the answer.  He won’t know the answer until he pulls the trigger.

Big things depend on the “little decisions” Emergency Physicians make, or choose not to make in a hundredth of a second.  If you’re right, the patient lives.  If you’re wrong the patient loses life or limb.  If you shock that mildly unstable heart rhythm, will the heart rhythm return to normal, with a life saved, or does the rhythm accelerate into fatal Ventricular Fibrillation?

I’ve had to answer these questions before, and lives have depended on my answers.  I get it.  Doctors get it.  Pilots get it.  Soldiers get it.  Police officers get it.  Bomb defusers get it.  If you tap a keyboard for a living, you probably don’t get it.  That’s okay.  We’ve got it for you.

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This author does not divulge protected patient information.  Any post that appears to resemble a real patient is by coincidence.  This author does not post, has not posted and will not post about real patients.  Although these posts may be inspired by the author’s experiences, they are not about real patients, because that would violate patient confidentiality.  If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail WhiteCoat.

 

Chief Violetté and the Headless Trauma

Tuesday, July 24th, 2012

By Birdstrike M.D.

It was intern year of my Emergency Medicine residency.  I was on my trauma surgery rotation and working at least 100 hours per week (pre-ACGME regulations). To say that I was burned out and sleep deprived would be an understatement.  It was three weeks into residency and I had done nothing but change dressings on my Chief resident’s patients’ putrid decubitus ulcers, run to get gauze packets, perform rectal exams, “RETRACT!”, and be the butt of senior resident jokes.  I had learned so few real skills in procedures or anything else that I was seriously ready to quit at this point, but in way too much student loan debt to do so.  I can’t tell you how many times I prayed for this guy to end up blind, impotent and in an adult diaper.  My supervising resident, Chief “Violate” … I’m sorry, let me rev up my French accent, Chief Violetté was infamous for getting his first two surgical residencies shutdown due to his generally abusive nature, not to mention his penchant for being an exquisite jerk at the perfect moment.  At his program’s ACGME site visit, when he was asked why he logged 168 work hours three weeks in a row during his first surgery rotation, his response was,“I wanted to work 170 hours, but when I got to 168, there were no more hours left in the week!”  I must say, despite being a bastard with no equal, old Chief “Violate”(as I will refer to him from now on), made me take my game to another level.

It’s Saturday night.  I’m on call.  I’m dead asleep, and let’s just say I’m feeling a little “pukey” and abso-friggin’-lutely exhausted from having a little too much fun the night before at the local nursing school graduation after-party.  I hear this insanely loud pounding on my call room door and our medical student is screaming, “Wake up!  Wake up!  The Chief’s got an intubation for you!  He wants you in the trauma bay in 30 seconds!!” In a deep circadian haze, I run down to the trauma bay,  and Chief Violate grabs my ear, pulls me into trauma room 1 and says, “I’ve got a procedure for you, big boy.”  I look down at the patient on the stretcher and see a pair of boots, blue jeans, a belt, a man’s tattooed chest, a perfectly normal neck and … a bloody stump of a partial-head pouring out blood like a lawn sprinkler.  As my sphincter tone increases rapidly to diamond cutting levels, the Chief puts a Mac 3 in my left hand and a 7.5 ET tube in the other, pushes me to the head of the bed and says, “You’ve been whining about not getting any good procedures, so cock, lock and get ready to rock, tough guy!”

To everyone’s shock and amazement, the guy is alive!  He’s conscious!  Choking on blood he screams, “Finish me off!  Finish me off, and put me out of my misery, you bastards!”  Apparently, instead of pointing the shotgun at the back of his throat towards his brainstem which would certainly have been instantly fatal, he put it in his mouth and pointed upwards, tearing off his upper teeth, maxilla, nose, eyes, forehead and frontal skull, leaving the key parts of his brain intact.

As my heart rate creeps up to near SVT levels, the Chief painfully flicks my ear and says, “What the hell are you waiting for?  Intubate him, All-Star!  Don’t worry.  This will be the easiest airway of your life.”  Only having intubated sedated animals and rubber dummies and never having intubated any patients that shot their faces off before, clueless, I begin to make my move.  “Just wait ‘till he takes a breath, and shoot for the bubbles.  You can’t miss,” says the Chief Violator.  Trying to see beyond the blood splatters on my face shield, I realize he has a very good point.  What intubation can be easier than one where you can literally look down the patient’s airway without any “face” to get in the way?  I wait. He takes a breath.  Out comes a bubble and in goes my tube.  Score!  First life saved: “check”.  First intubation: “check”.

“Alright, cowboy.  Nice intubation.  Are you ready for the hard part?” says the Chief.  Not believing that there could possibly be a “harder part” I answer, “Yes”.  “Now it’s time for you to go tell his family the good news and the bad news,” the Violator-in-Chief shoots back.  “There’s good news?  What the hell is the good news?” I ask.  “The good news is that he shot his face off,” he says.  Even more puzzled, I ask, “What’s the bad news then?”  The Chief’s answer, “The bad news is that he’ll probably survive.  Good job tonight, bro.  You da’ man.  The trauma service is yours tonight.  Only call me if someone needs an operation.”

I walk alone to the family consult room, take a deep breath, and open the door.  Standing there is a pretty young woman, the patient’s only daughter, not likely more than a few weeks over the age of 18.  She is strangely expressionless, stoic almost.  “How’s my dad?” she asks.  I am oddly more anxious about breaking the news to her, than I was actually during the trauma code.  “He shot himself,” I say.  Showing no emotion, “Is he alive?” she asks.  “Yes he is,” I answer.  “Is he going to make it?” she asks.  “It’s too early to say, he has terrible injuries to his face and head.  He’ll be in the ICU indefinitely.  I’m very sorry, that this has happened,” I answer.  Expressionless, she says, “Thank you,” and walks away without asking to see him.

After my heart rate drifts back safely below SVT range, but not before I can go to the bathroom to check my underwear to see if I unloaded in my pants during the trauma code, it becomes clear that faceless John Doe is anything but a “John Doe” to us.  According to his chart, he is a “frequent flyer” to our ED for various drunken, disorderly and violent acts.  In fact, 6 years before as a medical student, the Chief himself had sewn his now missing face back together after it was fileted open multiple times by the police after resisting arrest.  The crime: rape.  The victim: his then 12 year-old daughter.

After a few hellish weeks, bloodied, blind and in agony, his condition worsens.  A family conference is called.  The only one in attendance other than the ICU team: his only daughter, now of adult age in control of his fate.  They discuss his prognosis: grave, at best.  The options, they explain, are as follows: 1) To keep him alive, intubated on life support, in a painful living hell, or 2) To extubate him and let nature take its course, which will likely bring death quickly.  They explain to her, that to be aggressive, to keep him alive in this state would likely be nothing but futile and immeasurably cruel, and that most certainly he will die anyways, but in much more prolonged agony.  They also explain that to extubate him would mean that he will likely die quickly and painlessly, that this is by far, the more humane option.

The ICU team had talked amongst themselves beforehand, all knowing that years earlier he had cruelly and repeatedly raped her.  In a way that they never had before, they secretly hoped that she would ask them to make him suffer and choose the cruelest of all fates for him, to keep him alive and prolong his suffering and agony.  Certain, and secretly hoping, that she would bring him to justice by keeping him alive and instructing them to prolong his “prison sentence” of pain and living hell, they decided that either way, they would respectfully follow her wishes.  They anxiously wait for her answer.

“Extubate him,” she says.  “Let him die.”

Jim Dwyer New York Times Article – Irresponsible Journalism?

Wednesday, July 18th, 2012

By an Anonymous Emergency Physician

The opinion piece below was written by an emergency physician regarding a New York Times article by Jim Dwyer (picture at right). The author did not want to be identified due to fears of retribution from either the NY Times or from the hospital at which the physician is employed.

In addition to the points the author raises below, I would add these additional points of information:

1. The “Stop Sepsis” campaign cited in Mr. Dwyer’s article specifically stated that it is only to be used for tracking patients with severe sepsis and that “only those patients who are hypotensive after being given 2L of fluids or that have an elevated lactate should be entered in the data portal for this Collaborative.” Rory was not hypotensive and no lactate level was included in the labs pictured in Mr. Dwyer’s article. Mr. Dwyer never mentions any of these facts. The Collaborative does not allow access to links on this page describing its screening tools or to how it believes that a determination for ordering a lactate level should be made.

I will also note that Mr. Dwyer responded to some of the more than 1600 comments to his article, including some of the issues raised below, in this follow up article.

-WC

UPDATE JULY 22, 2012
Also see an important update to this debate at this link.

——————————————

The New York Times published an incredibly sad story about a 12 year old boy named Rory who went into the NYU emergency department, was diagnosed with gastroenteritis (a viral stomach bug), and who was dead two days later from septic shock.  Those are just about the only facts that are not in dispute.  The rest of the New York Times article seems to build a mountain of evidence as to why the emergency physician screwed up.  However, as is frequently the case, the truth is much more complicated than the media would have you believe.  There are lots of comments from other doctors using the almighty retrospectoscope and so many clinical inaccuracies discussed that this sad story is turned into a piece of sensationalistic journalism.

This post is mostly for the non-medical people that read this blog to help you understand the medical issues a little better.  This is a scientific discussion of the main inaccuracies of the article followed by what possibly could have been done better.  I say “possibly” because I did not examine the patient and all of my information is through the New York Times article.  If you have already read the article and decided that the ED doctor screwed up and nothing can change your mind, then stop reading.  If you want a fair and evidence-based discussion of the article then read on.

  1. The article references the “Stop Sepsis” campaign and says that the vital signs that should have triggered an evaluation for severe sepsis.  The article says that Rory had initial vital signs of a temperature of 102, a heart rate of 140, and then points to the Stop Sepsis guidelines.  There are two problems with this: First, the Stop Sepsis guidelines are intended to be used in adults, not in children. Second, just because a patient has abnormal vital signs doesn’t mean that they have severe sepsis.  Most patients in a pediatric ED waiting room would meet these criteria and yet they don’t have severe sepsis.  The “Stop Sepsis” guidelines are a screening tool that can suggest sepsis but they have to be used in the right clinical context.  Most physicians see pediatric patients every day who meet the “Stop Sepsis” criteria and who would best be described as having “the sniffles.”
  2. The article states that Rory’s temperature at home was “104, his highest ever.”  The implication is that this high fever, in of itself, should have triggered a more thorough investigation.  This is a misconception that must be dispelled.  A temperature of 106.7 degrees and above is the only time a fever by itself is dangerous.  Significant literature shows that a fever less than 106.7 degrees is not harmful.  We see children in the ED all the time with “high fevers” but that look great and would not have been considered sick without their temperature being taken at home.
  3. After Zofran and IV fluids, Rory felt better.  His vitals before discharge were a temp of 102 and a pulse of 131.  The article continues to allege that these vital signs met sepsis criteria.  However, a heart rate of 110 is the upper limit of normal for a 12 year old and, in general, a patient’s heart rate increases by about 10 beats per minute for every 2 degree increase in body temperature.  In Rory’s case, a heart rate of 131 was appropriate or just above the upper limits of normal for his temperature.  The persistence of a fever should also not cause worry just by itself.  Physicians frequently discharge febrile children from the ED without any adverse consequences. When assessing patients for discharge, what matters most is how the patient looks. According to the documentation in this case, Rory looked better before he was discharged.
  4. The article alleges that the emergency physician didn’t see the vital signs before she wrote the discharge instructions.  While this may be true, there are several more likely explanations.  In order to be efficient, I sometimes write discharge orders on patients that I think are going home because I have a minute free to put the order in. Technically, the orders are entered before the vital signs are entered, but this is for the sake of efficiency. I still evaluate the patient prior to discharge. Another possibility is that it the nurse didn’t have the time to put Rory’s vital signs into the computer before he was discharged. It is likely that the ED physician saw Rory’s vital signs while she was in the room re-evaluating Rory and signed the discharge order before the nurse entered the vital signs.  The way the article is written, it implies that the ED physician could never have seen the vital signs, but in reality, there is no way to tell for sure without asking the physician.
  5. The article implies that the white blood cell count of 14.7 should have triggered a more aggressive workup.  There is a mountain of evidence to say that a high WBC count does not rule in or rule out an infection or severe sepsis.

In order to keep this balanced, here are some things that I believe could possibly have been done better in Rory’s case.

  1. Discharging the patient before labs were back.  While this is sometimes done in cases of cultures or other “send out” tests, it is generally not a good idea to discharge patients before labs results are reported.  The most concerning lab in Rory’s case was the elevated number of bands or immature white blood cells at 53%.  High band count can be a red flag in the right clinical situation, but may also be a sign of a vigorous immune system response to a viral infection.  In addition, Rory’s carbon dioxide was normal.  In severe sepsis one would expect Rory to have acidosis and a low carbon dioxide level. A normal carbon dioxide level suggests that Rory may not have had severe sepsis at the time of his first ED visit.  Instead, he was probably in the early stages of sepsis which can be very difficult to distinguish from a simple viral illness.  A more thorough review of the labs may have prompted an admission for observation, but without having examined the patient no one can make that call.
  2. Rory’s vital signs at discharge were at the upper limits of what could be considered normal given his fever.  While the vital signs did improve, when I read the article the first time I admit that the discharge vitals raised an eyebrow.  However, as I previously noted, a child’s appearance is probably the most important indicator of severe illness and the ED physician is the only person who examined Rory.

I would like to end this article with a plea to the public to not crucify this ED doctor.  The New York Times should not have published the doctor’s name.  She is not a public figure and she has not been named in a lawsuit.  It is egregious that the New York Times published her name and thus unleashed the public venom on a private citizen.  I can guarantee that the ED doctor feels terrible about this case.  We don’t need the rest of the world coming down on her as well.  Even worse, due to federal patient privacy laws, the physician is prohibited from speaking about this case.  In any other profession, if a newspaper published something condemning your professional abilities you would be able to give your side of the story.

This case is every ED doctor’s worst nightmare and it can happen to the best of us.  As Greg Henry says, cases like this make you say to yourself “only by the grace of God go I.”  Cases like this keep physicians up at night.  The New York Times didn’t see it that way and wrote a sensational article condemning the ED doctor involved.  The reality is that very rarely, kids get sick and die.  Sepsis is a cruel disease and it can take a child that is otherwise healthy and looks great and kill them within hours to days.  It is no one’s fault – it is just bad luck.  Sometimes we catch that needle in the haystack and no one hears about it.  Sometimes we don’t and then it becomes front page news.  Let’s not make this situation worse by placing all the blame on this ED doctor.  This is a terrible case and while we should always try to learn and be better for the next patient, sometimes bad things just happen.

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